Cardiac metastasis of head and neck squamous cell carcinoma

Abstract

Two patients with cardiac metastasis from head and neck cancer are reported. Cardiac metastasis located in the left atrium was detected on a follow-up computed tomography (CT) scan 15 months after partial glossectomy for a tongue carcinoma in a 60-year-old man. The diagnosis was confirmed as cardiac metastasis of squamous cell carcinoma (SCC) by surgical excision of the cardiac lesion. The patient died 3 weeks after surgery. In a 69-year-old man with a partial maxillectomy for primary soft palate cancer, a follow-up CT scan 5 months after surgery revealed a mass in the right atrium and ventricle, and multiple lung metastases. He died of heart failure 3 weeks after the diagnosis of cardiac metastasis. Information on these cases should add to knowledge about rarely encountered cardiac metastasis.

Cardiac metastasis of head and neck squamous cell carcinoma (SCC) is rare in the literature. Patients are rarely diagnosed while still alive, and such cases are generally diagnosed at autopsy, because they often present no clinical symptoms. The authors report two cases of cardiac metastasis from head and neck cancer. One case was detected as a solitary metastasis; the other was diagnosed as part of widespread metastases in its terminal stage.

Case 1

A 59-year-old male visited the authors’ department in January 2004 complaining of a right lingual mass and oral pain. The mass extended to the midline of the tongue, and its size was 45 mm × 30 mm. The histological diagnosis of the biopsy specimen was well differentiated SCC. Computed tomography (CT), positron emission tomography (PET), and magnetic resonance imaging (MRI) detected lymph node metastasis to the right superior deep cervical node, and he was staged as having carcinoma of the tongue T2N1M0 (Stage III). He had no history of smoking or alcohol drinking. His electrocardiogram was within the normal range at the time.

The patient was treated concurrently with induction chemotherapy with S-1 (120 mg/day for 14 days) and external beam radiotherapy for a total dose of 30 Gy. Subsequently, he underwent a partial glossectomy and right radical neck dissection, and received a reconstructed rectus abdominis musculocutaneous flap in March 2004. After discharge, he received adjuvant chemotherapy (UFT 600 mg/day) for 2 months. No evidence of local recurrence had been noted on routine follow-up examinations.

In June 2005, the patient developed a marked fever and had elevated C-reactive protein in the blood after he underwent the repair of an abdominal incisional hernia. A chest CT scan and echocardiogram showed a mass reaching from the left atrium to the left pulmonary vein, and pericardial effusion. The left lower pulmonary vein was occluded by the mass ( Fig. 1 a and b ). The cytology results of the pericardial fluid were positive for malignancy ( Fig. 1 c). In diagnostic imaging examinations, he did not have any other metastasis or another primary tumour. He had not shown any other clinical symptoms.

Fig. 1
Cardiac metastasis detected by imaging studies. (a) CT and (b) echocardiogram images of case 1, 4 months after primary surgery, showing a left atrial mass (arrows). (c) Photomicrograph of the cytology gleaned from the cardiac effusion. LA, left atrium; LV, left ventricle; RA, right atrium; and RV, right ventricle.

The patient underwent surgery by a cardiovascular surgeon to remove the tumour in order to delay the growth of the mass up to the mitral valve ( Fig. 2 a and b ), but he died of heart failure 3 weeks after surgery. That tumour was considered to be cardiac metastasis of oral cancer, as the pathological diagnosis of the tumour was SCC ( Fig. 3 a and b ).

Fig. 2
Macroscopic views and illustration of case 1 during cardiac surgery. (a) The presence of the protruding tumour in the left atrium. The left lower pulmonary vein (PV) was occluded by the tumour. (b) The pedunculated tumour was resected from the root of the mass.

Fig. 3
Microphotograph of the primary tumour and the cardiac metastasis. (a) A biopsy specimen of the primary tumour in the tongue was diagnosed as well-differentiated SCC. (b) The isolated tissue from the left atrial mass was diagnosed as cardiac metastasis of SCC. The histopathological images of the protruding tumour in the left atrium were similar to those of the primary carcinoma of the tongue.

Case 2

A 69-year-old male visited the authors’ department in January 2010 with the chief complaint of a left palatal mass. The ulcerative tumour reached from the soft palate to the hard palate, and was 30 mm × 32 mm in size. It did not invade the nasal cavity or the maxillary sinus. The histological diagnosis of the biopsy specimen was well-differentiated SCC. The patient had a past history of smoking. CT, PET, and MRI detected lymph node metastasis to the right superior deep cervical nodes. No evidence of distant metastasis was noted in any of these examinations. The disease stage of the soft palatal mucosa cancer was classified as T2N1M0 (Stage III).

The patient underwent preoperative chemotherapy with S-1 (120 mg/day for 14 days) and radiotherapy at a dose of 40 Gy at the primary site and the cervical lesion. He was treated by surgery via a partial maxillectomy and radical neck dissection. After discharge, he received adjuvant chemotherapy (S-1 120 mg/day) for 2 months.

5 months after surgery, a follow-up CT study confirmed the presence of a 52 mm × 30 mm mass in the right atrium and ventricle. It indicated that there was a large amount of pericardial effusion ( Fig. 4 a) . His echocardiogram showed tumour progression around the coronary artery. The mass had reached the tricuspid valve and its mobility was depressed ( Fig. 4 b). His electrocardiogram showed a right bundle-branch block that was evident on admission, and a borderline Q wave not shown on admission ( Fig. 4 c). A cardiac MRI and PET-CT showed carcinomatous pericarditis and multiple lung metastases ( Fig. 4 d). The patient refused aggressive therapies, and died 3 weeks later.

Jan 24, 2018 | Posted by in Oral and Maxillofacial Surgery | Comments Off on Cardiac metastasis of head and neck squamous cell carcinoma
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